Coordinator - Heart Failure

Thomas Jefferson University•Camden County, NJ

3d•Onsite

About The Position

Assumes an active role in the overall Heart Failure (HF) program development at JNJ. Works collaboratively as a team member with HF Specialists / APPs / RNs and ancillary AHPs to oversee population management of Heart failure (HF) patients via real-time identification of inpatients with a diagnosis of HF on a daily basis. Tracks appropriateness of care setting and resource utilization, assists with the identification of advanced HF patients, collaborates with clinical staff to ensure optimal GDMT, ensures an appropriate discharge plan, and coordinates both patient/family and staff education regarding HF. Works with hospital-based Quality Improvement staff to maintain metrics on HF outcomes such as readmissions, Length of Stay, and HF Quality indicators. Coordinates Quality Improvement processes for HF care, including GWTG requirements. Oversees/provides Transitional care after discharge for patients transitioned to rehabilitation facilities, skilled facilities, personal care facilities, outpatient programs, and home with home care or home as per the Hospital to Home (H2H) guidelines. Provides coaching to clients to enable them to gain disease self-management skills and cope with transitions across care settings. The patient population ranges from young adulthood through late adulthood. Works closely with Outpatient HF Clinic staff.

Requirements

Bachelor’s Degree in Nursing
2 years cardiac nursing experience.
Knowledge of hospital and community resources
Experience with heart failure specific disease management knowledge
Excellent verbal communication skills
Computer skills
Time management and prioritization skills
Reliable transportation and auto insurance
Self-directed and independent in structuring work processes
CDL-C - Class C Driver's License_PA - State of Pennsylvania
RN - Licensed Registered Nurse_NJ - State of New Jersey or RN - Licensed Registered Nurse_PA - State of Pennsylvania

Nice To Haves

Master’s Degree in Nursing
Heart Failure experience preferred.

Responsibilities

Assumes active role in overall HF program development at JNJ.
Works collaboratively as a team member with HF Specialists / APPs / RNs and ancillary AHPs to oversee population management of Heart failure (HF) patients via real time identification of inpatients with diagnosis of HF on daily basis.
Tracks appropriateness of care setting and resource utilization.
Assists with identification of advanced HF patients.
Collaborates with clinical staff to ensure optimal GDMT.
Ensures appropriate discharge plan.
Coordinates both patient / family and staff education regarding HF.
Works with hospital based Quality Improvement staff to maintain metrics on HF outcomes such as readmissions, Length of Stay and HF Quality indicators.
Coordinates Quality Improvement processes for HF care including GWTG requirements.
Oversees / provides Transitional care after discharge for patients transitioned to rehabilitation facilities, skilled facilities, personal care facilities, outpatient programs, and home with home care or home as per the Hospital to Home (H2H) guidelines.
Provides coaching to clients to enable them to gain disease self-management skills and cope with transitions across care settings.
Works closely with Outpatient HF Clinic staff.
Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
Follows established guidelines of the H2H Program and the Interact Tools, the transitions coach will implement.
Provides consultation, education and support to patients and patient caregivers related to care giving responsibilities.
Maintains effective working relationship with medical team and all agency personnel providing care to the patient.
Supports the medical staff during patient encounters as needed, performs diagnostic testing, patient education, and patient treatments as directed.
Maintains effective collaborative communication with multidisciplinary team members in maintaining quality care for the patient.
Documents all care management activities for each patient/client.
Attends educational activities and departmental meetings as required.
Prepares and submits timely and accurate statistical reports on HF related metrics and transitional care interventions.
Performs other duties as assigned.

Benefits

medical (including prescription)
supplemental insurance
dental
vision
life and AD&D insurance
short- and long-term disability
flexible spending accounts
retirement plans
tuition assistance
voluntary benefits
tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.